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How To Reduce High-Risk College Drinking: Use Proven Strategies, Fill Research Gaps
Promoting Healthy Behaviors Through Individual- and Group-Focused Approaches
Individual- and group-focused prevention and treatment approaches include a number of tested
strategies. Prevention-oriented strategies include motivational enhancement techniques,
cognitive-behavioral interventions, including expectancy challenges, and educational/awareness
programs. Treatment-oriented strategies also include brief intervention, in addition to more
intensive traditional treatment approaches. Accessible screening and recruitment programs are
essential for service delivery. Hybrid approaches may combine elements of both prevention and
treatment strategies to respond to the special needs of campus-based college students.
Summary of Relevant Research
There is a larger body of research on individual- and group-focused approaches in college
populations than there is for environmental strategies. Collectively, individual- and
group-focused interventions have proven valuable in both preventing and treating alcohol problems.
Prevention
Effective college drinking prevention programs frequently employ a multicomponent approach. For
example, one study randomly assigned 348 high-risk freshman students to receive or not receive a
45-minute, in-person session that included feedback on students’ personal drinking behavior and
negative consequences; accurate information about alcohol-related norms on campus and comparison
of their personal drinking habits to actual campus norms; and advice or information regarding
drinking reduction techniques (Marlatt et al., 1998). This approach combined brief motivational
enhancement with normative reeducation, skills training, and information.
Brief Motivational Enhancement
The Panel reviewed a series of related studies that provide strong support for the efficacy of
brief motivational enhancement (Anderson et al., 1998; Aubrey, 1998; D’Amico and Fromme, 2000;
Dimeff et al., 2000; Marlatt et al., 1998; Monti et al., 1999). Motivational enhancement is based
on the theory that individuals alone are responsible for changing their drinking behavior and
complying with that decision (Miller et al., 1992). Interviewers assess student alcohol
consumption using a formal screening instrument. Results are scored, and students receive
nonjudgmental feedback on their drinking behavior and its negative consequences. Students also
receive suggestions to support their decision to change (Miller et al., 1992). Studies on
motivational enhancement report significant reductions in alcohol consumption and negative
consequences such as driving after drinking, riding with an intoxicated driver, traffic
violations, and injuries. In addition, brief motivational enhancement techniques work in a variety
of contexts, including emergency rooms, outpatient counseling centers, fraternity organizations,
and with randomly selected high-risk college freshmen. Brief interventions are described in more
detail below under “Treatment.”
The research also suggests that in-person feedback and interpersonal interaction may not be
essential to the success of brief motivational enhancement. One researcher provided computerized
self-assessment and feedback with good results (Dimeff et al., 2000), and three other studies (Agostinelli
et al., 1995; Walters, 2000; Walters et al., 1999) showed positive results with mailed feedback,
although larger-scale studies of this approach are warranted.
Cognitive-Behavioral Skills Training
Cognitive-behavioral skills-training programs are a relatively new addition to the college
drinking prevention repertoire. These programs teach skills to modify beliefs or behaviors
associated with high-risk drinking, although many also incorporate information, values
clarification, and/or normative reeducation components within the skills-teaching context (Garvin
at al., 1990; Marcello et al., 1989). Cognitive-behavioral programs range from specific
alcohol-focused skills training (including expectancy challenge procedures, blood alcohol
discrimination training, or self-monitoring/self-assessment of alcohol use or problems) to general
life skills training with little or no direct relationship to alcohol (such as stress-management
training, time-management training, or general assertiveness skills) (Garvin et al., 1990; Murphy
et al., 1986; Rohsenow et al., 1985).
Expectancy challenge programs show students that their expectations about how they and their
peers will behave after drinking alcohol can affect that behavior. This strategy may include
either direct experience, including the use of placebo beverages that students believe contain
alcohol, or education on and discussion of expectancy issues.
One study randomly assigned heavy-drinking male students to consume beverages in a social setting
and participate in activities including a social or sexual component (Darkes and Goldman, 1993).
The students then attempted to guess which participants (including themselves) had consumed
alcohol based on their behavior. Performance on the task was no better than chance. In addition,
participants received information about how expectations of alcohol’s effects can influence
behavior and monitored expectancy-relevant events in their environment throughout the course of
the 4-week study. The intervention comprised three 45-minute sessions.
The Panel reviewed three studies, including the one just summarized (Darkes and Goldman, 1993,
1998; Jones et al., 1995), that indicated that this technique may have considerable utility for
decreasing alcohol use among college males. Of particular note is the finding that the greatest
effects occurred among those who drank more heavily. Evidence suggests that the direct experience
component may be important to success, but more research is needed to confirm it. More studies are
also needed to replicate these findings on a larger scale and evaluate the utility of this
approach with women.
Another fairly simple cognitive-behavioral intervention asks students to document their current
or anticipated alcohol consumption in writing or on the computer. In one study, students recorded
their daily alcohol consumption for 7 weeks (Garvin et al., 1990), while another asked students to
complete a diary anticipating alcohol consumption and problems for an upcoming spring break week
(Cronin, 1996). The third asked students to assess their drinking via computer three times during
their freshman year (Miller, 1999). All three studies support the potential of this approach for
controlling consumption and reducing negative consequences (Cronin, 1996; Garvin et al., 1990;
Miller, 1999). However, due to methodological limitations, additional research is needed to
confirm findings.
Ineffective Approaches Used in Isolation
For the past two decades, educational approaches have been most commonly used to combat high-risk
college student drinking (Moskowitz, 1989; Ziemelis, 1998). These traditional approaches are based
on the assumption that students primarily abuse alcohol because they are unaware of its health
risks. The theory is that increasing knowledge about negative effects will lead to decreased use.
However, there is very little evidence to suggest that knowledge deficits are related to high-risk
alcohol use in this population or that a change in knowledge leads to a change in behavior (Moskowitz,
1989).
Several outcome studies evaluating traditional informational programs with college students have
been conducted in the past 15 years. Most found no effect on either alcohol use or negative
consequences. Although many of these outcome studies suffer from serious methodological
limitations (Larimer and Cronce, 2002), a recent meta-analysis of the college alcohol prevention
literature from 1983 to 1998 concluded that typical education- and awareness-based programs
(including values clarification approaches) produce, on average, only small effects on behavior (Maddock,
1999). These findings suggest that although education may be an essential component in skills
training, brief motivational enhancement programs, and expectancy challenge, pursuing
informational approaches in the absence of other integrated comprehensive programs is a poor use
of resources on college campuses.
Treatment
Time-limited, patient-centered counseling strategies that focus on changing alcohol-related
behavior have proven effective in treating college students with diagnosed alcohol problems. As
with the prevention programs described previously, brief intervention techniques are also used and
can be efficiently delivered in a variety of settings including student health clinics, counseling
centers, and peer counseling programs. Easy to teach and easy to learn, most techniques can be
effectively passed on in 1- or 2-day training programs.
Elements of Brief Intervention
The clinical elements of brief treatment intervention include the following steps:
- Conduct an assessment: “Tell me about your drinking.” “What do you think about
your drinking?” “What do your parents or friends think about your drinking?” “Have you had any
problems related to your alcohol use?” “Have you ever been concerned about how much you drink?”
- Provide direct and clear feedback: “As your doctor/therapist, I am concerned
about how much you drink and how it is affecting your health.” “The car accident/injury/emergency
room visit is a direct result of your alcohol use.”
- Establish a treatment contract through negotiation and goal setting: “You need
to reduce your drinking. What do you think about cutting down to three to four drinks, two to
three times per week?” “I would like you to use these diary cards to keep track of your drinking
over the next two weeks. We will review them at your next visit.”
- Apply behavioral modification techniques: “Here is a list of situations when
college students drink and sometimes lose control of their drinking. Let’s talk about ways you can
avoid these situations.”
- Ask patients to review a self-help booklet and complete a drinking diary: “I
would like you to review this booklet and bring it with you at your next visit. It would be very
helpful if you could complete some of the exercises in the book.”
- Set up a continuing care plan for reinforcement phone calls and clinic visits.
“I would like you to schedule a followup appointment in one month so we can review your diary
cards and I can answer any questions you might have. I will call you in two weeks. When is a good
time to call?”
In studies testing brief intervention, the number and duration of sessions varied by trial and
setting. The classic brief intervention performed by a physician or nurse usually lasted for 5 to
10 minutes and was repeated one to three times over a 6- to 8-week period. Other trials that used
therapists or psychologists as the interventionist usually had 30- to 60-minute counseling
sessions for one to six visits. Trials in which therapists conducted the interventions used
motivational interviewing techniques extensively. Some trials developed manuals or scripted
workbooks. In others, the interventionist decided how to conduct the intervention based on a
training program. Some studies used the FRAMES mnemonic as a guide for the intervention (Miller
and Sanchez, 1994).
Effects of Brief Intervention
Brief intervention talk therapy delivered by primary care providers, nurses, counselors, and
research staff can decrease alcohol use for at least 1 year in nondependent drinkers in primary
care clinics, managed care settings, hospitals, and research settings (Bien et al., 1993; Fleming
et al., 1997, 1999; Gentilello et al., 1999; Kahan et al., 1995; Marlatt et al., 1998; Ockene et
al., 1999; WHO, 1996; Wilk et al., 1997). In trials with positive outcomes, reductions in alcohol
use varied from 10 to 30 percent between the experimental and control groups. One trial followed
patients for 48 months and found a sustained reduction in use (Fleming et al., 2000).
The effect size for men and women is similar (Fleming et al., 1997; Manwell et al., 1998; Ockene
et al., 1999; Wallace et al., 1988; WHO, 1996). The effect size for persons over the age of 18 is
similar for all other age groups including older adults (Fleming et al., 1997, 1999; Marlatt et
al., 1998; Monti et al., 1999; Ockene et al., 1999; Wallace et al., 1988; WHO, 1996). Brief
intervention appears to work in young adults and students under the age of 25 who are not alcohol
dependent (Fleming et al., 2000; Marlatt et al., 1998).
Brief intervention can also reduce health care utilization in the general population (Fleming et
al., 1997; Gentilello et al., 1999; Israel et al., 1996; Kristenson et al., 1983). Studies
including Project TrEAT (Trial for Early Alcohol Treatment) found reductions in emergency room
visits, hospital days, hospital readmissions, and physician office visits (Fleming et al., 1997;
Gentilello et al., 1999; Israel et al., 1996; Kristenson et al., 1983). Brief intervention can
also reduce alcohol-related harm. For example, a number of studies have found a reduction in blood
levels of gamma-glutamyltransferase (GGT), an index of liver damage (Israel et al., 1996;
Kristenson et al., 1983; Nilssen, 1991; Wallace et al., 1988), sick days (Chick et al., 1985;
Kristenson et al., 1983), drinking and driving (Fleming et al., 2000; Gentilello et al., 1999;
Monti et al., 1999), and emergency room and trauma center injury admissions (Gentilello et al.,
1999).
Promising Approaches for Increasing Student Recruitment and Retention
in Prevention and Treatment Programs
Despite the advances made in developing and testing efficacious prevention approaches, many
students do not participate in these programs. Those who need them most appear to be least likely
to use them. In fact, one study found that 46.2 percent of male drinkers and 39.57 percent of
female drinkers had no interest in participating in even a minimal intervention involving
informational brochures and flyers (Black and Coster, 1996).
Two approaches have been identified that may be effective in increasing student recruitment and
retention:
- Using social marketing techniques to construct and advertise programs (Black and Coster, 1996;
Black and Smith, 1994; Gries et al., 1995).
- Incorporating screening for and, in some cases, the intervention itself into standard practice
at campus health centers and emergency rooms (Dimeff et al., 2000; Monti et al., 1999).
Panel Recommendations: What Colleges and Universities Can Do Now
The Panel recommends that colleges and universities:
- Use brief motivational interventions, such as providing feedback on students’ personal
drinking behavior and negative consequences, comparing individual drinking habits to actual campus
norms, and teaching drinking reduction skills. Strong evidence of effectiveness supports these
relatively low-cost interventions.
- Increase screening and outreach programs to identify students who could benefit from
alcohol-related services.
- Train those who regularly interact with students, such as resident advisors, coaches, peers,
and faculty, to identify problems and link students with intervention services and/or provide
brief motivational interventions. This allows colleges and universities to improve services
without adding new staff.
- Use educational interventions that provide new information such as describing alcohol-related
programs and policies, informing students about drinking-and-driving laws, and explaining how to
care for peers who show signs of alcohol poisoning. Use alcohol education in concert with other
approaches, such as skills training or social norms.
- Avoid using educational efforts focused primarily on facts about alcohol and associated harm
as a sole programmatic response to student drinking. They have proven to be ineffective.
- Be inclusive of varied student subpopulations. Determine and address the special needs of
groups such as racial/ethnic minorities, women, athletes, Greeks, students of different ages, and
gay and lesbian* students.
Panel Recommendations: What Researchers Can Do To Address Gaps in
Knowledge
The Panel recommends that researchers address the following questions to fill key gaps in
knowledge:
- What are the campuswide effects of implementing individual- and group-focused interventions?
- How well do these interventions work with different campus populations, including Greeks,
incoming students, mandated students, adult children of alcoholics, athletes, students at various
risk levels based on current alcohol practices, students living on and off campus, and members of
different ethnic, religious, and cultural groups?
- How effective are student-to-student interventions?
- What are the most effective uses of computer-based technologies in college alcohol
initiatives?
- Should approaches be tailored to the needs and situations of underage students versus those
age 21 and older?
- What are the most effective and cost-effective ways to conduct outreach for alcohol services?
- What criteria are appropriate for diagnosing college student alcohol problems? Do they differ
from the general population criteria used in currently available instruments?
- How well do pilot programs work when taken to scale on different campuses?
* Term used in broad sense; includes students who are bisexual, transgendered, and questioning as well as gay and lesbian.
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Last reviewed: 9/23/2005
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